Commentary
H5N1
Spread Across Java in Indonesia
Recombinomics Commentary
15:02
November 24, 2008
There was a “strong indication” that poultry markets across western Java were affected, the National Committee for Bird Flu Control and Pandemic Preparedness said Friday.
The above comments describe the level of H5N1 in poultry markets on Java. Official numbers are uncommon, because Indonesia has not filed an OIE report on H5N1 poultry outbreaks since they declared H5N1 endemic in 2006. Similarly, Indonesia has stopped sending poultry samples to the WHO regional lab in Australia for confirmation and sequencing.
Indonesia has the highest number of confirmed human H5N1 cases, but much evidence suggests the official numbers represent a gross under-count. The case fatality rate in Indonesia is around 80% and has been at that level since the first human case was confirmed 3 1/2 years ago. However, many patients are treated late in Indonesia, which increase case fatality rates, and many patients treated early test negative on Ministry of Health assays. Therefore the virulence of H5N1 in Indonesia is unclear.
Recently, there was a large cluster of H5N1 cases in Makassar. Seventeen patients were admitted over a two day period, and the first seven tested were lab confirmed. All 17 are likely to recover, but none of these cases are likely to be classified as official cases because the Ministry of Health has claimed that all lab tests are negative.
Negatives in Indonesian clusters are not uncommon. A large cluster in Garut produced three H5N1 cases, but relatives of the confirmed cases died with bird flu symptoms, and were not tested, while others developed symptoms and were promptly treated with Tamiflu and tested negative.
False negatives in Tamiflu treated patients was also suggested by comments by the head of the Ministry of Health who cited prompt treatment for a reduction in confirmed cases. However, prompt treatment would reduce infections if the H5N1 was easily transmitted, but the number of confirmed cases could also be reduced by a lowering of H5N1 below cut-off points.
The high level of H5N1 in markets in Java, coupled with the lack of any confirmed human cases since July, again raise concerns of gross under-reporting.
Concerns are increased by a lack of comment by WHO.
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